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in Cardiac Arrest Management

Current Events. in Cardiac Arrest Management. Sean Kivlehan, MD, MPH, NREMT-P September 2013. 3 In Depth Medication Use Hypothermia Intubation. 5 Quick Info Vascular Access Cardiocerebral CPR CPR Devices Termination Rules Current Trials. Plan. Please think about…..

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in Cardiac Arrest Management

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  1. Current Events in Cardiac Arrest Management Sean Kivlehan, MD, MPH, NREMT-P September 2013

  2. 3 In Depth Medication Use Hypothermia Intubation 5 Quick Info Vascular Access Cardiocerebral CPR CPR Devices Termination Rules Current Trials Plan

  3. Please think about….. 1. Why do we do what we do? 2. How can we do it better?

  4. What they already knew: • Compressions affected ventilation • If alone, only do compressions • “Only the human hand is required”

  5. Clear Airway, esophageal airway or intubation • Push down 4-5cm and minimize interruptions to <5 sec (20 sec for intubation) • Defib at max dose (400J) • Epi, Isoproternal, Calcium, Bicarb, Lidocaine, intracardiac injections

  6. Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study • Before/After study in 17 cities of BLS vs ALS • 2867 patients with major trauma • Overall survival: no difference • GCS <9 survival: • 50% with ALS • 60% with BLS Stiell IG, Nesbitt LP, Pickett K, et al. The OPALS Major Trauma Study: impact of advanced life support on survival and morbidity. CMAJ 2008 Apr 22;178(9):1141-52

  7. “The best available observational evidence indicates that epinephrine may be harmful to patients during cardiac arrest, and there are plausible biological reasons to support this observation.” Caveat: “However, observational studies cannot establish causal relationships in the way that randomized trials can.” Callaway CW. Questioning the use of epinephrine to treat cardiac arrest. JAMA 2012 Mar;307(11):1198-200

  8. Norway 2003-2008 IV drugs vs no IV drugs 6 years, 851 patients ROSC: 32% vs 21%: BETTER Survival to discharge: NO CHANGE Favorable Neuro Outcome: NO CHANGE 1 year survival: NO CHANGE Overall, no improvement Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009;302(20):2222–2229

  9. Western Australia 2006-2009 Epi vs Placebo 4 years, 534 patients ROSC 23.5% vs 8.4%: BETTER Survival to discharge 4.0% vs 1.9%: NO CHANGE (OR 0.7-6.3) No statistically significant improvement Jacobs IG, Fimm JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011 Sep;82(9):1138-43

  10. Hesitant to participate? • 4/5 EMS services wouldn’t participate because of “withholding standard of care.” • Voluntary participation: only 40% of medics • Negative press & ethics concerns affected funding What is “Standard of Care?” “To date the evidence base underpinning this “standard of care” intervention has been restricted to animal and non-randomised clinical studies that are characterised by inconsistent findings. The extensive barriers … serve only to ensure such interventions remain unproven.

  11. March 2012 Epi vs Placebo Japan, 4 years, 417,188 patients ROSC: 18% vs 5%: BETTER 1 month survival: NO CHANGE Good functional status: 1.4% vs 2.2%: WORSE (OR 0.21 – 0.71) prehospital epinephrine was significantly associated with increased chance of ROSC but decreased chance of survival and good functional outcomes 1 month after the event. Why? • Increased lactate, over-constriction of microcirculation, metabolic debt overall • Promotes dysrhythmias, activates platelets Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012;307(11):1161–1168

  12. The Debate Continues Shockable rhythm: WORSE Non-shockable: MAYBE BETTER (if given in <20 min) • Looked at: • ROSC (better) • 1 month survival (better) • 1 month neuro outcome (same) Goto, Critical Care, 2013

  13. Is Speed the Issue? “Early Epi” study 911 to epi <10 min or greater than 10 min 686 patients • Avg 911 to Epi time = 14.3 min • 155 (22.6%) received Early Epi • Better ROSC • No change in Admission or Discharge Koscik, Resuscitation, 2013

  14. What About Vasopressin? 2012 meta-analysis Vasopressin vs epi in 6 RCT’s No improvement in: • Sustained ROSC • Long term survival • Favorable neuro outcome Higher long term survival in asystole(slight) Mentzelopoulos SD, Zakynthinos SG, Siempos I, et al. Vasopressin for cardiac arrest: meta-analysis of randomized controlled trials. Resuscitation 2012 Jan;83(1):32-9.

  15. Steroids? • Vasopressin • Epi • Methylprednisolone 40mg Saline Epi Saline VS. ROSC: 2.98times more likely Survival to DC w/ good neuro status: 3.28more likely Mentzelopoulos, JAMA 2013

  16. Therapeutic Hypothermia

  17. In Hospital – 2002 Study #1 • 77 patients randomized to 33°C x12 hours • Favorable neuro outcome: • 49% chilled • 26% not Study #2 • VF post arrest, 136 patients randomized to 32-34°C x24 hours • Favorable neuro outcome: • 55% chilled • 39% not 6 month mortality down 14% No difference in complication rate Bernard SA, Gray TW, Buist MD, et al: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.N Engl J Med 2002, 346:557-563 Hypothermia after Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.N Engl J Med 2002, 346:549-556

  18. EMS Use: Post-Arrest Australia 2010:ROSC after VF PRCT: Rapid infusion of 2L ice-cold NS by EMS after ROSC vs hospital cooling Favorable neuro outcome: 47.5% vs 52.6% (p = 0.43) [No difference] Australia 2011:ROSC after Asystole/PEA Same approach, same results Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized, controlled trial. Circulation 2010 Aug 17;122(7):737-42 Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med 2012 Mar;40(3):747-53

  19. Intra-Arrest • Before/after study in North Carolina • 551 patients, 2L 4°C NS intra-arrest vs None • ROSC: 36.5% vs 26.9% (OR 1.19-2.81) • Hospital discharge not statistically significant Garrett JS, Studnek JR, Blackwell T, et al. The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrest. Resuscitation 2011 Jan;82(1):21-5

  20. NYC Project Hypothermia Before/after study (2009-2011); 10,309 arrests • 30 cc/kg up to 2L @ 4ºC via large-bore IV/IO • after defibrillation and airway management, but before any drugs Working?avg cooled by 1.6ºC (35.6 to 34) Harming?8% get pulmonary edema Helping?32.5% (38% with >1500cc) vs 27.9% NYC Project Hypothermia Working Group, Freese J. Intra-arrest induction of therapeutic hypothermia via large-volume-ice-cold saline infusion improves immediate outcomes for out-of-hospital cardiac arrest. Circulation 2011;124:A2 (Resuscitation Science Symposium 2011 Presentation)

  21. Outstanding Issues Route:IV, Intra-nasal evaporative, Ice packs/lavage Induction:Intra-arrest vs post-arrest & if so how long after ROSC Rhythm:VF/VT only or all Trauma patients?(J Trauma case series 2011) Optimal temperature? When to rewarm? Summary: IATH improves survival and neurological outcome Scolletta S, Taccone FS, Nordberg P, et al. Intra-arrest hypothermia during cardiac arrest: a systematic review. Crit Care 2012 Mar 7;16(2):R41

  22. Intubation Update

  23. ETI vs SGA Witnessed nontraumatic OHCA x4 years in Japan 5,377 patients Favorable neuro outcome 3.6% vs 3.6% Longer time to placement for ETI: 17.2 vs 15.8 min (p<0.001) Kajino K, Iwami T, Kitamura T, et al. Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Crit Care 2011;15(5):R236

  24. “Out of Hospital Airway Management in the United States” NEMSIS data from 16 states in 2008 4.3 million EMS calls 10,356 ETI: success 77% (Hubble, 2010 showed 86.3% in meta-analysis of 30 studies) 1,794 alternate airways: success 87% [Combitube, EOA, LMA, King LT] Wang HE, Mann NC, Mears G, et al. Out-of-hospital airway management in the United States. Resuscitation 2011 Apr;82(4):378-85 Hubble MW, Brown L, Wilfong DA, et al. A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates. Prehosp Emerg Care 14(2010):377-401

  25. Harming > Helping? Michiganretrospective study 1995-2006 1,515 arrests, 86.2% intubated Overall survival to discharge: 6.5% vs 10.0% (intubated vs not) VF/VT survival to discharge decreased with intubation Californiaretrospective study 1994-2008 1,294 arrests, 79.4% intubated Survival to discharge: BVM 4.5x more than intubation North Carolinaretrospective study 2006-2008 1,142 arrests, ROSC 5.4x more likely in nonintubated pts Egly J, Custodio D, Bishop N, et al. Assessing the impact of prehospital intubation on survival in out-of-hospital cardiac arrest. Prehosp Emerg Care 2011 Jan-Mar;15(1):44-9 Hanif MA, Kaji AH, Niemann JT, et al. Advanced airway management does not improve outcome of out-of-hospital cardiac arrest. Acad Emerg Med 2010 Sep;17(9):926-31 Studnek JR, Thestrup L, Vandeventer S, et al. The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Acad Emerg Med 2010 Sep;17(9):918-25

  26. Japan Again • 5 year observational study • 649,359 patients • 43% with airway • WORSE neuro outcome • 1.1% vs 2.9% (OR 0.38) Hasegawa, JAMA, 2013

  27. Hasegawa, JAMA, 2013

  28. IO as first line in arrest? [182 arrest patients] 1st attempt success: Tibial IO: 91% Humeral IO: 51% PIV: 43% Time to initial success: Tibial IO: 4.6 min Humeral IO: 7.0 min PIV: 5.8 min Reades R, Studnek JR, Vandeventer S, et al. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial. Ann Emerg Med 2011 Dec;58(6):509-16

  29. CPRvsCCR Continuous Chest Compression (CCC) CPR Preferred by bystanders Equivalent or better resuscitation rates Cardiocerebral CPR • 200 uninterrupted chest compressions @100/min • Rhythm analysis with a single shock if indicated • Immediately followed by 200 postshock chest compressions before any pulse check or rhythm reanalysis. • ETI delayed until after 3 cycles • IV epi administered as soon as possible during the protocol and again with each cycle More Info: SHARE Program @ Univ. of Arizona Sarver Heart Center Ewy GA, Sanders AB. Continuous chest compression CPR preferred for primary cardiac arrest. Resuscitation 2010 Jun;81(6);639-40 Bobrow BJ, Clark LL, Ewy GA, et al. Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest JAMA 2008;299(10):1158-1165

  30. Compressions Systolic Blood Pressure Time (Seconds)

  31. Increasing Bystander CPR Hallstrom, NEJM 2000

  32. CPR Adjuncts Load Distributing Band CPR (AutoPulse) 2004-5 ASPIRE Trial, US multicenter RCT Lower survival & worse neurological outcomes Halted early (dangerous) Mechanical Piston Device (LUCAS) 2005-2007 Pilot Study in Sweden, 148 arrests No difference in early survival Impedance Threshold Device (ITD) 2007-2009 US multicenter RCT, 8,718 arrests No difference in survival Halted early (futility) Smekal D, Johansson J, Huzevka T, et al. A pilot study of mechanical chest compressions with the LUCAS device in cardiopulmonary resuscitation. Resuscitation 2011 Jun;82(6):702-6 Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 2006 Jun 14;295(22):2620-8 Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. NEJM 2011 Sep 1;365(9):798-806

  33. What went wrong? 4 hour survival same Hospital discharge 5.8% vs 9.9% “Results are unexpected and there is no obvious explanation” • Hawthorne Effect for CPR & Learning curve for device • Delay to use? • Enrollment bias?

  34. “no alternative technique or device in routine use has consistently been shown to be superior to conventional CPR for out-of-hospital basic life support” (2010 AHA Guidelines) “The experts are aware of several clinical trials of the devices listed below that are under way and/or recently concluded, so readers are encouraged to monitor for the publication of additional trial results in peer-reviewed journals and AHA scientific advisory statements.”

  35. Termination & Capnography Significantly Associated with ROSC: • Witnessed Arrest (OR = 1.51) • Initial EtCO2 >10 (OR = 4.79) • EtCO2 falling <25% of baseline (OR = 2.82) Alternatively: • Male, no bystander CPR, unwitnessed collapse, non-VF arrest, initial EtCO2 <10, and EtCO2 falling >25% • 97% predictive of no ROSC Eckstein, 2011

  36. Termination Rules But, HOW LONG? Morrison, Resuscitation 2009

  37. CURRENT RESEARCH

  38. sean.kivlehan@gmail.com

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